Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0228, written 17 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jul 2018 |
|---|---|
| Reference | 2018-0228 |
| Deceased | Leslie Bingham |
| Coroner | Christopher Dorries |
| Coroner area | South Yorkshire (West) |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS This report is being sent to Mr John Mothersole, Chief Executive, Sheffield City Council CORONER Christopher P Dorries OBE, HM Senior Coroner for South Yorkshire (West) CORONER’S LEGAL POWERS 2 | | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION In January 2017 | commenced an investigation into the death of Mr Leslie Bingham. The investigation concluded following an inquest in June 2018 where the Jury’s narrative conclusion (copy attached) was to the effect that Mr Bingham died from injuries received when he was hit by a police vehicle whilst crossing the A61 Penistone Road at Owlerton Green. CIRCUMSTANCES OF THE DEATH Mr Bingham had approached the A61 along Owlerton Green on his way to a family celebration at the Greyhound Stadium. He was not affected by drink or other substances. The exact path taken from the kerb on the West side of Penistone Rd (ie: adjacent to the Pizza Hut) is unknown but Mr Bingham got safely onto the first pedestrian refuge which is roughly triangular in shape. At this point he had only crossed the lane for traffic turning left into Owlerton Green and still had the two northbound lanes of the A61 to cross. The evidence was that Mr Bingham then stepped into the northbound lanes of the A61 notwithstanding the approaching police vehicle. It is clear that the traffic lights for the police vehicle were on green. The final conclusion of the jury as to the crossing itself reflected evidence (and in particular a viewing) as regards the positioning of the red/green pedestrian indicator lights on the triangular refuge. Mr Bennett from the City Council was present throughout and can no doubt assist you further but in summary the jury feared that a pedestrian approaching from Owlerton Green might be misled by a green pedestrian light intended only for those crossing the mouth of Owlerton Green in a northbound direction. The sequence is such that this (first) light will be green for a large part of the time that the pedestrian indicator to cross the northbound lanes of Penistone Road is red. The first light has been designed to be particularly bright with a narrow viewing angle but it is highly visible to those approaching from Owlerton Green, particularly if the corner to reach the refuge is cut very slightly. The jury were plainly of the view that Mr Bingham may have had only this bright green light in mind as he progressed towards the refuge and thought that this gave him clearance to cross the A671 in front of the approaching traffic which he may well have assumed was being shown a red light. | would respectfully agree with the jury's conclusion on this point. Whilst this is a difficult junction to provide for, it remains a significant hazard with a high likelihood of serious injury for anyone who makes this error. ——— CORONER’S CONCERN During the course of the investigation my inquiries revealed a matter giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 5 | The MATTER OF CONCERN is as follows -- The evidence showed that there was a significant possibility that a pedestrian approaching the A61 from Owlerton Green adjacent to the Pizza Hut may be misled by a green light intended for pedestrians crossing the mouth of Owlerton Green and thus miss a red light prohibiting them crossing the northbound lanes of the A61. | therefore make this report. ACTION SHOULD BE TAKEN 6 | In my opinion action should be taken to prevent future deaths and | believe you the Sheffield City Council have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 7 | namely by 12" September 2018. | may extend this period upon request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the family of Mr Bingham (via Messrs Irwin Mitchell, solicitors), the South Yorkshire Police and the driver of the police vehicle. lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Professor Christopher P Dorries OBE HM Senior Coroner, South Yorkshire (West) 17” July 2018
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Chief Executive: John Mothersole MA Sheffield Town Hall - Sheffield - S1 2HH : City Council Tel: 0114 273 4002 - Fax: 0114 273 6844 ‘th Our ref: JM/HCP/G145 4" September 2018 Mr Christopher P Dorries Office of H.M. Coroner HM Senior Coroner The Medico Legal Centre Watery Street Sheffield S3 7ET Dear Mr Dorries Mr Leslie Bingham (deceased) Thank you for your letter and enclosed Regulation 28 report concerning the inquest into the death of Mr Leslie Bingham dated 16" July 2018. | note from the report that you have a concern, namely; MATTER OF CONCERN The evidence showed that there was a significant possibility that a pedestrian approaching the A61 Penistone Road from Owlerton Green adjacent to the Pizza Hut may be misled by a green light intended for pedestrians crossing Owlerton Green at the junction and thus miss a red light prohibiting them crossing the northbound lanes of Penistone Road. RESPONSE The investigators are aware of concerns raised by the jury relating to the layout of pedestrian crossing Puffin Nearside Signals (PNS) at this location when approaching the site on Owlerton Green to cross Penistone Road. The jury were concerned that pedestrians may be confused and misread which pedestrian signal is relevant to them. The PNS at this location are ‘Narrow Field of View’ units (for the Green Man display), to overcome the possibility of misread at the crossing points. Their alignment was checked and they were re-aligned post installation in 2015 to minimise this problem. It was subsequently noted than when approaching the crossings from the tactile paving at the correct crossing positions opposite the island on Owlerton Green, there is no longer such potential for the PNS to be misread (see the photograph below). Large print versions of this letter are available by telephoning 0114 273 4201 This also applies to the situation when a pedestrian is standing on the island, as the green man signal is still not visible when walking between the crossing points. There is no history of any pedestrian collisions other than the fatality at this location in the three years since the changes were made (up to the end of April 2018) which would suggest that the signals are working safely when used correctly. Whilst there is not an issue with signal ‘read-through’ if pedestrians cross from the tactile paved area at the correct crossing point, the Council agrees with the findings of the Coroner and the jury that should an Eastbound pedestrian walking along Owlerton Green cross towards the corner of the island, away from the designated crossing point, a green man signal on the PNS could be misread. A photo showing the view from this point is shown below. It should be noted that when a pedestrian is standing at the tactile paved area on the triangular island waiting to cross Penistone Road, the green signal (if currently displayed) on this PNS would no longer be visible to them, due to the narrow angle of view of the equipment. However, the PNS to their right which would be clearly visible to them, and from where traffic is approaching on Penistone Rd, would display a red man pedestrian signal (if Penistone Rd traffic currently has a green signal). It is possible that a pedestrian stood in a position such that they had a view as shown in the photograph above could, upon seeing this green man signal, head straight towards the central reservation on Penistone Road and attempt to cross without looking towards oncoming traffic and the correct PNS, which would be showing a red signal for pedestrians. There does not appear to be any scope to further re-align the PNS, without losing the benefit of this signal for pedestrians crossing Owlerton Green. Additionally, there is no scope to move the PNS to an alternative location. This is due to the small size of the island and the need to cater for blind and partially sighted pedestrians, who need to be able to find the PNS and push button below it on their right-hand side when standing on the tactile paving waiting to cross. Whilst further alterations to the signals on the triangular island do not appear to be feasible, an effective alternative would be to deter pedestrians from cutting across the slip road in the wrong location and guide them to the designated crossing point. This can be done by providing a length of barrier rail around this corner of the junction. -4- This should address the concerns expressed by the Coroner and the jury. An illustration of such a barrier arrangement is shown below. A length of guard rail sufficient enough to discourage pedestrians from walking around it on the carriageway side would be required. However, the inter-visibility between cyclists entering the carriageway from the off-road shared cycleway/footway and drivers turning left into Owlerton Green from Penistone Road also needs to be taken into account. Leaving a small gap between the cycle give-way and the start of the barrier as shown above and making sure that the barrier rail is a “Visirail’ type thereby making it easier for cyclists and drivers to see through it, would in the opinion of Council officers address this whilst still being sufficient to discourage pedestrians from crossing at a potentially more hazardous location. It is anticipated that this new pedestrian barrier rail will be installed on site within 10 weeks of our response to this report. Yours sincerely John Methérsole Chief Executive
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